The Terrible Gift

Terrible Gifts
Sometimes we may have even given them, either on purpose… or worse, by accident. We’ve also received them on purpose… or worse, by accident.

Several years ago, knowing my brother was very much an avid hiker and camper, I bought him a present which was both utilitarian and stylish. The gift was comfortable and when you put them on, you looked like you were ready to tackle Mount Everest without breaking a sweat. I knew he would love them. In fact, I was a bit reluctant to give them away.

Yet, when my brother opened his present on Christmas Eve, for the first time, I saw the gift through his eyes… he didn’t view them as the thrilling gateways to adventure and exploration. All he saw was socks. Wool socks. Green, with red stripe.

At that point, I could almost read his mind…. Is this a joke? What are you kidding? Thanks, brother. What’s next year’s gift, underwear?

The fact that he later wore the socks, liked the socks, loved the socks, did not (and to this day does not) stop him from reminding me that this was possibly the lamest Christmas gift he ever received.

Of course there are worse gifts (in the eye of the beholder), both accidentally and intentionally:

Taco Rob once got neon red Argyle socks. (So, brother Benson, I don’t feel so badly.)

Jeremy got a Tickle Me Gizmo (the Gremlin).

For a full year, for all occasions, people saw fit to give me unicorns. I got two more today.

My friend, Kip, received ladies underwear from his brother Danny.

Kip’s brother Danny once received a Star Trek t-shirt. Too small to wear.

My buddy, Doug, got a magenta (his word) hand-painted of Elvis.

Our embryologist, Shan, got a Heineken indoor grill from a cousin who got freebies through his work at a distributor.

Nicky, our andrologist, got Mariah Carey’s Rainbow.

My buddy Matt, laments receiving “The Audacity of Hope” – by Barack Obama (Knowing Matt, this was probably given intentionally).

Jeff Scotchie (Jessica’s husband) got stuck with “Don’t Hassle the Hoff” from Shan’s husband, Neal.

My buddy Ted received a used Chinese wok.

My friend Andrew got a $5 check from a great-great aunt with instructions to purchase a new “bonnet”.

So What’s the Point?

It was once said of James Michener, author of epic best-sellers like Hawaii, Alaska and Tales of the South Pacific, that it took him 50 pages just to say “hello”. If you’ve read my blogs before, you know I sometimes take a while before I get to the point.

Well, here we are again at the Christmas season, possibly the worst time of year for most patients suffering from infertility. They face this season knowing that they won’t have the opportunity to buy a toy for a child and to see the happy expression that toy brings or even the disappointment a bad gift brings. They fear they never will have that chance.

Last year, I wrote a blog about how to cope with the holidays. Rather than rooting around in the cumbersome blogspot, I’ve provided a link here, if you’re interested in reading it.

But this year, I want to focus on the terrible gift of infertility. It is terrible because it ushers so many opportunities for sadness and a sense of loss. It is the loss of a life that never was. It is terrible because the feelings it brings are often inescapable and frequently come without warning. It is terrible because it makes others frequently feel like they can’t speak to you about all the joys they experience with children and family – it can make friends censor themselves around you.

But I want to remind you of just one thing. Though terrible, infertility is still a gift. Only people who have been through war together know what kind of bond that can bring. While the war may have been terrible, the bond is the gift. Infertility may or may not be what is intended for you for the rest of your life. But it is a gift for now. It is a gift because it is an opportunity to build a bond with your spouse, and to help you understand those who are suffering with greater clarity.

I remember back when my wife and I had failed several IVF cycles. We could not get pregnant because of an issue with her fallopian tubes. I remember a time in my greatest sadness, thinking that if only, if only, if only…. If only I had married someone else, this curse would not have befallen me. I remember rolling that thought around in my mind, kneading it and shaping it until I finally realized that my love for my wife was so much greater than my need for a child. This terrible gift tested and strengthened my devotion to my wife.

Though terrible, it is also a chance of you to deepen your understanding that we live in a broken world. While there is great joy, within the world and our own community and even amongst our friends there is often great suffering and tribulation. We all know the world is not fair, but we don’t live like we understand that. Really the best we can do is to make the best of the gifts we receive, no matter how terrible they are.

Does my thyroid matter? - By Dr. Jessica Scotchie

There are many causes of infertility and recurrent pregnancy loss. Often the tests performed by Tennessee Reprodictive Medicine are screening tests to guide further investigation or treatment. Thyroid dysfunction is one condition that may affect our patients.

The thyroid gland is a small gland located in the neck, responsible for making thyroid hormones which help regulate metabolism. Thyroid dysfunction is very common, affecting up to 10% of the population at any given time. In general there are two forms of dysfunction: decreased thyroid hormone production (hypothyroidism) and increased thyroid hormone production (hyperthyroidism). Underactive disease, or hypothyroidism, affects 2-10% of individuals, and occurs 5-8 times as often in women than men. Overactive disease, or hyperthyroidism, is less common, affecting 1-5% of individuals. With both forms of thyroid disease, women are affected far more commonly than men (5-8x more often).

The symptoms of thyroid disease are easily recognized, but are also commonly seen in other disease presentations and among healthy individuals. Hypothyroidism presents with weight gain, fatigue, cold intolerance, hair loss, constipation, muscle aches, and difficulty concentrating. Hyperthyroidism often presents with weight loss, tremors, hair loss, anxiety, irregular heart beat (palpitations), and sweating. Both underactive and overactive disease can result in menstrual irregularities in women.

Most thyroid diseases are caused by autoantibodies against components of the thyroid gland. Antibodies are molecules made by our immune system to fight infection; in the case of auto-antibodies, our immune systems mistakenly make molecules to fight a part of our body that the immune system should recognize as a normal part of the body. The end result is organ damage, which either causes decreased thyroid hormone production (hypothyroidism) or increased hormone production (hyperthyroidism).

How do we screen for thyroid disease? Physicians will generally start with a thyroid stimulating hormone level (TSH). The TSH hormone is made in the pituitary gland (in the brain) and is sent to the thyroid gland to tell it to make thyroid hormone (think of the accelerator in your car). The thyroid then makes thyroid hormones (T4 and T3) which circulate back to the pituitary gland; the pituitary gland then recognizes that there is sufficient circulating T4 and T3 and keeps the TSH in a normal range (think of a feedback loop). When there is too little thyroid hormone, the pituitary should respond by increasing the TSH level (as if stepping on the accelerator harder to make the car go faster), therefore underactive thyroid disease typically presents with an elevated TSH level. In contrast, if there is too much thyroid hormone, the TSH is usually suppressed, because the high levels of T4 and/or T3 have signaled back to the pituitary that there is no need for TSH to keep signaling for more T4 and T3 to be made (think of the accelerator being pushed as hard as possible, there would be no need for you to push harder to go faster). There are other conditions in which this relationship is not as straightforward as just described, and for this reason it is important to rely on your physician to correctly interpret hormone results.

How do we treat thyroid disease? For the two abnormalities described previously, the goal is to restore the thyroid hormone levels back to normal. For hypothyroid disease, we replete the patient with thyroid hormone. Usually after about 4 weeks of treatment the TSH level is rechecked and the dose adjusted until the TSH is in a normal range. For hyperthyroid disease, treatment options include medications to suppress thyroid production (propylthiouracil and methimazole), radioiodine ablation, and surgical removal of the thyroid. The optimal treatment can be decided with your physician. There are other causes of thyroid diseases (tumors, cancer, nodular goiter) that are treated differently and beyond the scope of this blog.

You may be asking yourself, why does a fertility specialist care about the thyroid? The answer is normal thyroid function is critical for normal menstrual function and for optimal pregnancy outcomes. Hypothyroidism has been associated with increased risks of miscarriage, pre-eclampsia (blood pressure disease in pregnancy), and low birth weight babies. Untreated hypothyroidism can also result in mental deficiencies in children, which in the most severe form is known as cretinism. Some women do not have overt hypothyroidism, but have mild lab abnormalities that we would call subclinical hypothyroidism (high TSH but normal thyroid hormone levels). Subclinical hypothyroidism has also been associated with higher rates of miscarriage.

Hyperthyroidism is also associated with adverse outcomes, including pre-term delivery, pre-eclampsia, maternal heart failure, low birth weight babies, and miscarriage. Fetal hyperthyroidism can also occur as a result of maternal autoantibodies passing through the placenta, and causing fetal goiter (enlarged thyroid) which in severe cases can affect the mode of delivery.

Clearly, avoiding these complications is critical and generally easy to do by closely monitoring a woman’s TSH level and adjusting thyroid medications to keep the TSH level in a low-normal range (ideally < 2.5 mIU/ml in pregnancy). Women with hypothyroidism typically require increased doses of levothyroxine in pregnancy due to the expanding plasma volume that occurs in pregnancy. Women with hyperthyroidism are usually treated with oral medications, as radioiodine cannot be used during pregnancy.

The big central controversy with thyroid disesae at the present time is whether or not to screen all women who are trying to conceive or newly pregnant. We clearly know that overt over- and underactive thyroid disease is bad. We don’t have solid evidence that subclinical disease poses the same risk, or that treating women with subclinical disease improves these possible risks. There are two main professional societies that regularly review available medical evidence and make recommendations on practice guidelines for physicians. The American College of OBGYN currently does not recommend universal screening, on the basis that there is insufficient data to suggest that treating subclinical hypothyroidism improves obstetric outcomes. The Endocrine Society tends to lean more towards liberal screening, however they also do not recommend universal screening. They instead recommend screening any women with the following characteristics:

1. Infertility.
2. History of miscarriage or preterm delivery.
3. History of any thyroid dysfunction, or a family history of thyroid dysfunction
4. Presence of a goiter (enlarged thyroid).
5. Known thyroid antibodies.
6. Symptoms suggestive of disease as outlined above.
7. Type I diabetes.
8. Presence of other autoimmune diseases.
9. Prior head or neck radiation.

Most of the patients we see are infertility and recurrent pregnancy loss patients. In our professional opinion, due to the fact that treatment for thyroid disease (especially hypothyroidism) is generally well tolerated and has few risks, we feel that the benefits of treatment outweight the risks of treatment, and therefore screen most of our patients trying to conceive with a TSH level.

There Is Always Something To Worry About - Part 3

How to Get Pregnant and Have a Healthy Pregnancy

Step 3 – Getting Pregnant

When I meet an infertility couple, the first things I want to know are the age of the woman, her past reproductive history and how long this couple has been having intercourse without contraception. I’m generally not as interested in how long they’ve been “trying” to get pregnant. The reason I say this is because if couple has been “trying” to get pregnant for 6 months but have not used any form of birth control in six years, then they have 6.5 years of infertility. Their prognosis is frequently much worse than another couple who quit birth control 12 months ago and is not pregnant.

If you have not used birth control in 1-2 years and are not pregnant, call and make an appointment today to be seen by your provider or by us at 423-876-2229. If you are still truly in the early stages of trying to get pregnant, please continue to read.

Areas of Concern
When we give talks about getting pregnant, we frequently discuss 6 areas of concern: duration of infertility, adequate intercourse, adequate ovulation, adequate sperm, anatomy and ovarian reserve.

Of the six areas of concern, three are essential to conception and these are: a woman must produce an egg (ovulation), the man must have sperm, and the sperm and the egg must be able to meet (adequate anatomy.

Adequate Intercourse
Many couples who are trying to conceive fixate on exact timing of intercourse, when in truth exact timing is not particularly important. What is essential is that a couple has intercourse on, or prior to, the day of ovulation. Sex on a single day of the month has virtually the same chance of pregnancy if the sex occurs on the day of ovulation, the day before ovulation or even the day before that. Sperm can live up to 5 or 6 days and still fertilize. This means, for most couples, intercourse every 2-3 days is adequate.

Intercourse 24 hours after ovulation has a very low chance of pregnancy. After ovulation, the egg lives only about 12-24 hours. So make sure you have sex prior to ovulation if you want to conceive.

Ideally, adequate intercourse would mean satisfactory intercourse for both partners. Unfortunately, for the purpose of getting pregnant, it really only has to be satisfactory for the male – as he must deposit sperm into his partner. Female orgasm has no significant role in fertility. I know, it’s not fair.


Adequate Ovulation
Ovulation (producing an egg) is essential to getting pregnant. Most women who have regular predictable menses are ovulating. Ovulation is even more likely in regularly cycling women who reliably predict their menses because of breast tenderness or bloating or mood changes that precede the menses by a few days. Ovulation can be confirmed various ways, with basal body temperatures, ovulation predictor kits, or even a blood test. Ovulation is generally deemed adequate when the luteal phase is 11 days or longer based on basal body temperature charts or 12 days or longer based on ovulation predictor kits. For more details, click Ovulation.

Normal menstrual cycles are between 24-35 days. Shorter cycles frequently mean a woman’s ovarian reserve is declining and should be evaluated. Longer cycles can mean a woman is not ovulating and also should be evaluated.

Adequate Sperm
If a man has any sperm, it is possible to get pregnant; however, once sperm counts go below 15 million per ml, the chances of pregnancy can plummet significantly. Of course, we don’t recommend home sperm testing, because there are many facets of sperm which may affect fertility. Because it is a painless test, this should be the first test sought by a couple.

If there is a history of frequent sauna or hot tubbing, significant testicular trauma, testicular surgery, undescended testicle, prior radiation or chemotherapy, low libido, erectile dysfunction or low volume ejaculations then a more immediate evaluation should be pursued.

Adequate Anatomy
The fallopian tubes serve as a transit system for sperm and eggs. When a woman ovulates, the tube picks up the egg and holds it there for sperm to fertilize. For their part, the sperm are deposited in the vagina and have to swim through the cervical mucus, up through the uterus and out to the tube. Only 1 in a million sperm will eventually make it to the egg with intercourse.

□ If the cervical opening is small or scarred due to prior surgery it may not produce the needed cervical mucus which assists in the transport of sperm.
□ If the tubes are blocked, the egg and the sperm cannot meet.
□ If sheets of adhesions (scar tissue) separate the ovary from the tubes, getting pregnant can be a real challenge.
□ If benign tumors such as fibroids are growing in the uterus, this may prevent a pregnancy from taking hold.

Women with infertility for more than 1 year should have an x-ray called a hysterosalpingogram performed. For more details, click on HSG.

Endometriosis, a condition in which uterine lining grows outside the uterus, can sometimes distort the anatomy. Even when it doesn’t distort the anatomy, endometriosis can make getting pregnant more difficult. If you are just starting to get pregnant and you have a history of endometriosis, ask your physician if yours is so severe that you should do something about it. We’ll talk more about endometriosis and fertility in a future post. For more information now, click Endometriosis.

Ovarian Reserve
This is the biologic clock. The best predictor of the biologic clock is a woman’s age. By age 35, nearly 30% of women will be sterile. By age 40, nearly 70% will be sterile. In a study of women who never used any birth control and stayed married their entire lives, the last average pregnancy occurred at age 42. Many of these pregnancies ended in miscarriage because the embryos have a higher rate of being abnormal the older women get.

The biologic clock, or ovarian reserve, is determined by several factors: how many eggs a woman had at birth, how much damage has occurred to her ovary or eggs throughout her life, and how quickly she has lost her eggs.

Smoking, ovarian surgery, radiation and chemotherapy can all lead to premature depletion of eggs. Genetics can also cause early loss of eggs. We find that many women with unexplained infertility and with endometriosis have findings consistent with diminished ovarian reserve.

A sign that ovarian reserve is decreasing is a shortening of the menstrual cycle. Women who were regularly menstruating every 28 days, may find themselves having cycles every 24 days. This can be evidence of diminished ovarian reserve. The same goes for women who had PCOS and who never or rarely ovulated on their own who suddenly find themselves having normal menses.

If you have any of the risk factors above, strongly consider having your physician, or us, evaluate your ovarian reserve.

For more information click on diminished ovarian reserve.

If you have questions on any of the topics listed above, call us and make an appointment, visit our website: http://www.trmbaby.com/.

It’s a Mother of a Day

This week some of our patients have had some good news about their pregnancies and this Mother’s Day may be like no other. For them, this will be a joyful occasion, a day many of them never expected to have.

However, some of our patients and friends have had crushing news and are not yet pregnant, or are grappling with the possibility of never having a child. I know of others who have recently lost a child or a parent. I can’t imagine the sorrow a day like Mother’s Day may bring for them.

I can count my blessings for now, as both my wife and I still have our parents and we have our children. We can still celebrate this day with all the people who have been a part of our lives.

It is my hope and my prayer for all of those who are suffering a loss…either loss of what never or has not come to pass, or the loss of a parent or a child…can find a path to peace.

I well remember those Mother’s Days, waking next to my wife, when we were childless. It is a certainty that I felt sadness and fear. But I can tell you this: the sadness I felt was shared. It seems strange to say, but sharing a burrowing sadness was somehow comforting to me. The fact that I shared it with the person whom I loved more than any other person on the planet somehow made the sorrow not only bearable, but good.

My wife and I shared a sorrow. It was a sorrow wrapped, enveloped in a deep love…which in the end felt like a form of gratitude.

So this weekend, this is my wish for all of us, in case anyone has forgotten…. May you all have peace in your hearts and be grateful for your shared sorrow, cherish the ones you love, whether they are here or not. Cherish the Mother you were, the Father you were, or the one you could have been.

If you have lost a child or a parent, honor them by living a life which pays tribute to them.

It’s the rarest elements in nature that are valued so dearly. The time we have together here on earth is so small, so fragile and so very precious. We never know exactly what we will be given, or how long we will have it. I think we should all be thankful for what we have been given, no matter how briefly. If we have been given less, or have suffered loss…it is my hope that we can all appreciate even the small gifts as what they are….precious and rare.

This world contains enough sorrow that no one will ever go wanting for it. May we all recognize joy, too, and let it overflow from us and into others around us. If you know someone who is in the depth of sorrow and can’t find a way out, may you help to bring them peace.

Second Opinions

Ok, last time I posted here, I promised I'd write about how to get the most out of a second opinion. To do this, I did something a little novel - and so it took me longer than I expected. While I have pretty strong opinions on how to get the most out of a second opinion, I queried a lot of doctors from around the country to see what they would advise.


I have to say, overall, I was a little disappointed. Most of the responses were some variation of "send the patient to me."


Most advice was also not very helpful. A lot of the advise was almost opposite from the advise of other physicians.


To be fair, not all the people who responded were reproductive endocrinologists, so they may be quite in tune with the issues infertility couples face.


However, of the people I polled, there were some excellent points and issues to consider.


Why Get a Second Opinion?
There are many reason patients consider a second opinion. Frequently, in our field of medicine, it’s because a person did not have success with their previous provider, because they were given difficult news with few acceptable options, or simply because they did not mesh with their first provider. Sometimes, it seems some people get a second opinion because it’s just what they do… they like more than one opinion.


How to prepare for a second opinion:
1) First identify why you are seeking a second opinion (be aware of your agenda).
2) Be aware that your first and your second doctor may have an agenda, too.
3) Gather your records and get them to the physician ahead of time if possible.


Agendas are critical.

Agendas may completely alter the advice you receive.

First, the patient’s agenda: Almost every patient has a reason for getting a second opinion. Nearly every doctor I polled said that patients should know why they want a second opinion. If it’s because they just didn’t get the answer they were looking for from the first doctor, the patient needs to recognize this and keep this in mind when seeking a second opinion.


It has been said that the very poor and the very wealthy are at greatest risk for receiving the worst medical care. The poor have no access. The very rich can doctor shop until they find physicians who will do whatever the patient wants. Michael Jackson could always find yet another surgeon to carve him up or help him sleep. If you're just looking for someone to tell you what you want to hear, you should be aware that this can lead to sub-optimal treatment.

My advice to patients is, to the best of your ability, don’t tell the doctor your agenda until he or she gives his opinion.

Here is why.

There have been many times when patients come to my office for a second opinion and it is very apparent that they simply did not like what they heard from their first physician.

If I realize that the patient is very unhappy with the first doctor because of the opinion, I have a tremendous advantage compared to the first doctor. I already know what information, or what type of information that a patient does not like to hear. Simply agreeing with a patient’s preexisting biases may strongly influence the way the patient feels about my advice.

I would like to think this knowledge does not influence my opinion or how I relay information to a patient. I hope that’s not wishful thinking.

If I don’t know a patient’s agenda, then there is no opportunity for me to be influenced by this.

Knowing which advice is the best is not always easy. These are not fool-proof clues to which advice is best, but here are my suggestions:

*Did each doctor support their opinion, with evidence from the medical literature?
*Did each doctor explain the diagnosis to your understanding?
*Were you given a full range of options and the likelihood of each being successful?
*Does the doctor’s advice make sense?

The Doctors’ Agendas
Dr. Deane Waldman, of the University of New Mexico Health Science Center said that physicians providing a second opinion would ideally just be providing an opinion and not be gaining financially from such an opinion.

I frequently tell patients this, too. If a physician has nothing to gain from giving the opinion, he or she, is less likely to be influenced by his or her own gain. This kind of opinion is least likely to be biased.

So how does the patient learn if the doctor has an agenda?

In general, physicians in our field of medicine should really be providing you with information to help you make the very best choices. If their advice is good, they should not be threatened by the thought of you getting a second opinion.


Red Flags
There are certain circumstances when a first or a second opinion should cause you concern. (Preston Parry, an REI at the University of Wisconsin pointed out some of what follows below.)


1) False choices: I have encountered patients who have been told they either need donor sperm or in vitro fertilization. One couple had actually had two previous pregnancies over the past two years. In this case, the recommendation was made on the strength of a minimally abnormal semen analysis. (Clue 1: this advise didn't make sense, based on the patient history. Clue 2: a minimally abnormal result, even a moderately abnormal does not always mean extreme measures need to be taken.)


2) Only the positives are discussed. Every treatment has advantages and disadvantages. If you are offered only one treatment and the physician does not volunteer the disadvantages and advantages of all the options, then be wary. This is not to say the doctor is incorrect. But unless you really understand the upsides and downsides to all treatments, how can you make an informed choice?


3) It's Natural: the doctor suggests an array of supplements/holistic medicines. (Trying to prove that their practice is more thorough; the reality is if these things had a dramatic effect, everyone would be using them.)

4) It's what we do: the doctor suggests protocol modifications, but can’t say why it is appropriate through evidence-based medicine. (“We do it that way for everyone,” is not science, it’s opinion.)

5) Only We Syndrome: the doctor claims that he or his group has a unique procedure that only he can perform.


6) Cherry picking: This is a common concern among REIs (reproductive endocrinology and infertility specialists). There are some clinics which report extremely high success rates by age group. There is a suspicion among some REIs that some of these clinics are only treating good prognosis patients and trying to funnel poor prognosis patients toward egg donation. Without naming them, I will say this: I have referred some young, fairly poor prognosis patients to certain clinics for a second opinion and they have been told things like, "We wouldn't do a better job than your local docs." This is code for "we don't want you to hurt our statistics." Even if you are poor prognosis, a good clinic will give you realistic odds and should still let you proceed with care as long as you understand the chances and the treatment is not overly dangerous for you.



Conclusion:

Second opinions can be tricky. Ultimately it will come down to a matter of trust. If you get a second opinion, be sure that the physician fully explains why a recommendation is being made. If he or she can't explain it to you so that you understand it, then it likely is not the best choice for you.

If an alternative treatment is suggested, the relative advantages AND disadvantages should have been discussed with you.


You can ask your referring provider what their experience has been with the doctor. Ask your friends. Watch for red flags. And, ultimately, if all else fails, you should trust your instinct.

How Does Anyone Have a Baby?

If you are having difficulty getting or staying pregnant, you are not alone. At some point, infertility affects 15% of all couples. Recurrent pregnancy loss affects another 3% of couples.

If you are one of these couples, you may feel isolated and depressed. You will get all sorts of helpful and unhelpful advice from people (including yourself) who really do care. Perhaps one of the worst things someone can tell you is to “relax” or “quit trying so hard.” This advice generally has two effects:

To make you even more tense.

To make you think it’s all your fault.

At Tennessee Reproductive Medicine, we understand the stress that infertility and pregnancy loss causes. While it is true that in extreme cases stress can cause a woman to stop ovulating, very rarely is stress a cause of infertility. If stress isn’t causing the infertility, as so many people commonly think, let’s consider what is normal and abnormal in the world of conception so you can take charge of your fertility. 

Normal Conception Rates
After one year of adequate unprotected intercourse, 85% of couples ages 20-40 will be pregnant. Of the 15% who aren’t pregnant, half of those will be pregnant within the second year. The monthly chance of conceiving among couples in which the woman is less than 32 years old is approximately 20-25%. This illustrates that human reproduction is very INEFFICIENT! It may take some couples many months to conceive and this is within the range of normal. After age 32, monthly conception rates start to decrease slightly, then more significantly after age 35 to about 10-15% chance per month.

When Should I Seek Help Conceiving?
Infertility is considered the lack of conception after 12 months of unprotected regular intercourse (timed adequately during the suspected time of ovulation). All couples who have not conceived after 12 months warrant a full evaluation. While some couples will spontaneously conceive after 12 months of attempts, most will need some form of fertility therapy and further attempts at natural conception may be wasting precious time.

Furthermore, many couples warrant a sooner evaluation if there is a history suggestive of:

-ovulation disorders
-tubal disorders
-male reproduction disorders
-female greater than 35 years old
-endometriosis
-female with prior radiation or chemotherapy treatments

Do I need a fertility specialist?
Sometimes this is an easy question to answer, sometimes it's difficult. Consider your situation and conditions by taking this TRM Quiz at http://www.trmbaby.com/welcome/do_I_need_fertility.shtml. If the total number of points equals or exceeds 15 points, and you wish to conceive, strong consideration should be given to seeing a fertility specialist, specifically a reproductive endocrinologist.

Playing God - Part 2 and Part 3

The Pope and I are having a disagreement. Not a full-fledged brawl. But it’s a fight. And quite frankly, I’m a bit peeved at him. He is opposed to not only what I do for a living, but to how I conceived my children. He says I’ve violated their rights.

You read correctly. Pope Benedict XVI says my wife and I have violated my children’s rights by conceiving them the way we did.

I know this from his writings that are available through the Vatican Web site. This would probably bother me a lot, if I were Catholic. As a Presbyterian, I can be a bit more, well, philosophical.

Before he became the Pope, in 1987 Cardinal Joesph Ratzinger was the principle author of the Catholic Church’s position statement on treatments for infertility. I wanted to see how the Church justified its opposition to IVF, so I read it. The paper is titled, “Respect for Human Life” and is also known as the “Donum Vitae.” Translated literally, the Donum Vitae means the “gift of life.”

I was shocked by what I read. It wasn’t the conclusions that surprised me, but the rational and the basis for the rationale. At a minimum, I expected a scripturally-based argument. But it was (and is) not.

All told there are 64 references in this paper. Of these 64 references, only three are biblical passages. The remaining references are Papal and other Vatican writings.

The first quoted scripture noted that man should have dominion over earth. (I thought this sounded like an argument for IVF.) The other two scriptures said we should value life:

God created man in his own image and likeness: "male and female he created them, entrusting to them the task of "having dominion over the earth" (Gn. 1:27-28).

In the light of the truth about the gift of human life and in the light of the moral principles which flow from that truth, everyone is invited to act in the area of responsibility proper to each and, like the good Samaritan, to recognize as a neighbor even the littlest among the children of men (cf. Lk. 10:29-37). Here Christ's words find a new and particular echo: "What you do to one of the least of my brethren, you do unto me" (Mt. 25:40).

If that were all there was to the Donum Vitae, we would not really have an argument.

I agree that man, scripturally and by default, does have dominion over the earth. I also think we should value human life.

So exactly what is my beef with the Donum Vitae?

First let’s look at some of the declarations made by the Donum Vitae, then we’ll discuss them. I’ve paraphrased some of what comes below, because much of what the Church declares is obfuscated in ornate language (like this sentence.). The Donum Vitae says:

1. The child has the right to be conceived, carried in the womb, brought into the world and brought up within marriage and from marriage.


2. Donor insemination is immoral because it violates the rights of the child; it deprives him of his filial relationships with his parental origins and can hinder the maturing of his personal identity. Donor insemination is also wrong because it violates the child’s right to be conceived and brought into the world in marriage and from marriage.


3. Donor eggs are immoral for the same reasons as donor sperm.


4. Masturbation to achieve sperm is immoral.


5. Artificial insemination is permissible only when the procedure is not a substitute for the sexual act but instead facilitates the sexual act to have a child.


6. Fertilization achieved outside the body is immoral.


7. The freezing of embryos is immoral because an embryo may not survive and it deprives them temporarily “of maternal shelter and gestation, thus placing them in a situation in which further offenses and manipulation are possible.”


8. Life begins at conception.

Of course there is much more in the Donum Vitae about genetic testing and scientific research. I’m not going to focus on those issues during this entry, mainly because it would take too long, and only a small fraction of patients ever opt for these treatments.

Life Begins at Conception

The overriding issue addressed by the Donum Vitae is respect for human life. A key question is when does life begin? A reasonable position is the Church's position: life begins at conception. After all, an embryo is human; an embryo is alive. This is a reasonable assumption.

Others might argue that life begins in the sperm and the egg before fertilization. After all, the sperm and egg are both human, and both alive. Of course, we could argue that neither is a complete being.

So is an embryo a complete being? It usually has the genetic material to become one. But clearly an embryo is vastly different from a fetus, which is vastly different than a child, which is different from an adult. All are human. All are alive.

At what point does an embryo become a human life?

I would contend that if life is a gift from God then no matter the level of intervention, man cannot create life.

For example: in the lab, we cannot force a sperm to fertilize and egg. We cannot force the embryo to grow. We cannot force the embryo to implant in the uterus and to prosper. If we could do these things, our success rate would be 100%. As a specialty, we fall woefully short of this. All we can do in the lab is to create situations where fertilization is more likely, statistically. We can nuture embryos to the best of our abilities. But we cannot create a baby. Way too much is out of our control. This is at once humbling and reassuring to me.

It’s conceptually easy to believe that the human soul enters the embryo at the time of conception. After all, an embryo is alive. An embryo is human. Of course, these two points don’t make it a human being, no more than a fetus is a child, or a child is an adult. These are all points on a continuum and we don’t have the real ability to say when someone leaves childhood and becomes an adult. All we have are conventions. One convention says we become an adult at age 16, when we can drive. Another says 18, when we can vote. Another 21, when we can drink. Another 24, when we can rent an RV (at some rental shops in Colorado.)

I say all of this to show that it is convention to say that life begins at conception. Quite frankly that is how I have always, and continue to look at it.

But what if I’m wrong. If God is the giver of life, then when does He give an embryo a soul? Does this happen at the moment of conception? If so, then why are 50% of naturally achieved pregnancies lost prior to the onset of menses and the woman never knows she was pregnant? What would be the purpose of this? The truth is, we cannot know. The best we can do is to make our own assumptions. I look at it this way: an embryo is alive and it is human, but I know it’s not a child – yet. It is a potential child. For this reason, I would not elect to destroy my embryos.

This brings us to statement number 7, that Egg Freezing is immoral. The Church’s argument against egg freezing is that it places the embryo at risk and deprives it of maternal shelter. My response to this is that twin, triplet and quadruplet pregnancies can all do the same thing. High order gestations can create an environment that is unsuitable to sustain a pregnancy or might cause harm to the unborn child.

If I am creating embryos with IVF and not all of the embryos will be used, some of them might die if I freeze and thaw them. I am not trying to dispose of them. Rather, I am giving them a chance at life that they didn’t otherwise have. I am also maximizing their chance of having a safe pregnancy.

New freezing techniques are not perfect, but very few embryos are lost. Those that are lost, the intent is not to kill them, it is to save them so that they can be used. Yes, we place embryos at risk. How is this much different from a woman who is high risk for pregnancy who decides to conceive naturally? These pregnancies can be lost, too. Did she do something wrong? According to the Donum Vitae, this woman should not use contraception either.

Statement 6, saying that fertilization is immoral if it occurs outside the body. I don’t quite know what to say here, except, “According to whom?” Obviously, this is not in the Bible, so it is difficult to make a scripturally based argument against this. I think suitable scriptures to argue against the Church would be: “Man shall have dominion over the earth” and “Be fruitful and multiply.”

Statement 5, limiting the use of artificial insemination. Though the Donum Vitae doesn’t say this implicitly, this implies you can use a condom that has a small hole in it to allow some sperm to escape during sex, but you can then recover much of the sperm from the condom and use it for artificial insemination.

I at once welcome this exception, and yet I see the hypocrisy in it. The Donum Vitae is very clear that a child should be born of sexual relations between a man and wife. If the purpose of the sex is really to get sperm for IUI, rather than the IUI assisting the sex, it’s more likely that the sex act is assisting the IUI.

Statement 4, masturbation is immoral because the Church says so. No scripture is quoted to support this claim. I have looked for Biblical references on this. There is a lot about lust. Masterbation is not mentioned. So if lust is removed, then I see little to say this is wrong, espeically if it is being done to "be fruitful and multiply."

The story of Onan is commonly used to promote the idea that masterbation is wrong. However, as noted below, Onan's sin was not "spilling his seed" per se, but disobeying his father by refusing to help his dead brother's wife conceive a child.

Admittedly, we can get sperm from a Catholic-Safe Condom (one with holes in it); however, the results are less reliable.

Statements 2 & 3, donor egg and sperm are immoral because they deprive the child of its right to be conceived in the womb and of and from marriage. The reasons given by the Church have no basis in Biblical teaching. I hope I don’t go to Hell for what I am about to say, but even Jesus was conceived out of wedlock with 3rd party reproduction. Mary had the ultimate donor!

There is also reference to donor sperm, in Genesis. Onan was commanded to impregnate his dead brother’s wife, so that the brother’s clan line could be continued. When he refused to complete the act of sex and spilled his seed upon the ground, he was killed.

Onan was killed for disobeying the command to partake in the Biblical era's version of artificial insemination. He disobeyed his father and was killed for it.

One area where the Catholic Church and I can agree is that there is danger to this sort of reproduction. One of the ethical concerns with 3rd party reproduction is that children may grow up with a sense of loss if they do not know their genetic parents. This can be especially frustrating if it is thought that the parent is still alive and does not know.

It is in our nature to blame our anxiety on our circumstance in life. For example, if I were a minority and got bad service at a restaurant, I might wonder if it was the color of my skin. Or if I were a woman passed over for promotion so that a slightly less qualified man could be hired, then I might assume race or gender discrimination was a factor. Similarly, if a child is born from donor egg and sperm, he or she is also at risk for blaming the troubles in life on the fact that the biologic parent is unknown.

This is a very legitimate concern and while not all offspring suffer this, it is important to be aware of this potential problem prior to using donor eggs and sperm.

Statement 1, a child has the right to be conceived within the womb and born of and from marriage. I do not see this written anywhere that this is a child’s right. However, this has been frowned upon in the scriptures and through the ages. Jesus was sometimes referred to by Jews who opposed him as, “The Son of Mary,” meaning he was born out of wedlock.

I do believe that the best environment in which to be raised is in a loving home. I want there to be a mother and father in the house because this was how I was raised.

Final thoughts....

I think much of the debate around the Donum Vitae surrounds what is "natural." God's laws and natural laws are often seen as the same. But to say that an IVF baby was conceived unnaturally is to say that we are above God's laws, above nature. As a human, I am part of nature. Everything I do is part of nature. Kevlar is a natural product if man made it.

It is the hieght of vanity to assume that what man has made is above or outside of nature.

To an automobile is unatural is to say an anthill is unatural. The anthill was constructed. It's primitive, but constructed.

So my children, conceived with IVF were not conceived outside of nature. They were and are the product of a loving, committed relationship.

So, I did not violate my children's rights through their conception with IVF. The Pope owes me, and them, an apology.

I won't hold my breath waiting.

Playing God - Part 1

A few weeks ago, before an embryo transfer, my embryologist recited a Bible verse to me that she had given to my patient. The patient, had written down this verse on a scrap of paper and was taking it into the room to get her embryo transfer.

When Shan recited this verse and told me that the patient was carrying it, I felt a lump in my throat, a lump that is usually associated with great sorrow, or overwhelming joy and relief.

"That's strange," I thought and wondered why it made me feel so unexpectedly emotional.

It was like an aroma that transports you back in time, to a specific place, by-passing the normal circuits of memory. I was at once filled with specific and vague memories and feelings of joy, despair, love, shame and remorse. It was a tidal wave of regret and gratitude.

It reminded me of how small we are compared to the forces at work in the universe.

Despite my religious upbringing, I honestly could not recall ever seeing that verse. More likely, I hadn't been prepared to see it before.

It's humbling to realize that this was there all along, and it sums up something that took me years to understand.

So what was the verse?

1st Corinthians 2:9, "No eye has seen, no ear has heard, no mind has conceived what God has prepared for those who love him."

With that, let me get to the actual blog entry.

What I am about to write is not something just for people with a religious inclination. I think even an atheist will fall prey to some of the thinking that I talk about in this entry. If nothing else, perhaps it will help somebody else understand how another person feels (and fears). So hopefully, this entry will be of benefit to everybody.

******

When I was an Ob/Gyn resident, I told a nurse that I wanted to be a Reproductive Endocrinologist. As she looked back at me, a look of disgust spread across her face. “Why would you want to do THAT?” she asked. “It’s so immoral. It’s playing God.”

She proceeded to lecture me along these lines for several minutes before finally concluding that if people weren’t meant to have kids, then they should not have them and they had no right to be parents.

I asked her if she thought that my wife and I should not be allowed to have children.

“I didn’t say that,” she said.

“Yes, you did,” I told her.

This exchange allowed us to have what is sometimes called a teachable moment. Probably for the first time in her life, she saw what she said in context of an actual human being rather than a person on paper or in her imagination.

I told her that I didn’t know what God intended for my life. Despite using all the technology available to us, my wife and I had not conceived. Was this punishment for trying to play God? I had no way of knowing. But I did know this, no matter what I did, if God did not want me to have children this way, then my wife and I would be childless.

I think her mind changed that night. What changed it was not an argument, but a realization.

As my wife and I struggled with infertility, we wished there were clear signs telling us what we were supposed to do. Were we supposed to just stop? Or were we supposed to take advantage of all the treatment that God put before us? Was IVF a path to the garden? Or was it the forbidden fruit?

With each failure, in the midst of each great sorrow, we asked the same questions again… what were we supposed to do? Were we being sinful, or prideful wanting to have children that were biologically related to us? Were we following God’s commandment? Or were we pushing our wishes ahead of God’s will?

In the absence of signs, we persevered. We knew only one thing for sure: if we did not try, we would not conceive we would regret our decision later.

I personally have not met any patients who I thought were trying to play God. I’ve met people suffering from infertility, people like me and my wife, struggling to understand the plan, if any, for our lives.

The Unspeakable Truth

It was something we didn’t talk about.

Because we were both secretly ashamed of it, my wife and I didn’t admit it to each other. We barely wanted to admit it to ourselves. We certainly didn’t discuss it with even our best friends – some of whom may be reading this now.

And before I go on, let me say that I believe what I am about to tell you says much more about me and my wife than it does about our friends. At the same time, what I am about to describe is a nearly universal experience for couples with long-standing infertility.

So here goes.

When we were struggling to get pregnant and if you got pregnant… we hated you.

It’s true. (Though my wife denies this, officially.)

We hated you because you were so happy. We hated you because you didn’t want to tell us you were pregnant, because you didn’t want to hurt our feelings. We hated you because we felt abandoned. It was one more reminder that we were relatively alone in this predicament.

It was even hard to feel happy for other infertile couples who finally conceived. When they got pregnant we felt even greater abandonment.

Now there were times when I tried to soften this word, tried to work around it and redefine it. I’d call it anger at our situation. I’d call it envy, jealousy, resentment, spite…

But in the end, all those words and all those emotions still felt the same… they felt like hate or some other withering emotion.

And like hate, this emotion took much more of a toll on me and my wife than it did our friends.

In fact, I’m not sure anyone ever knew how we felt. My wife hosted baby showers for friends, visited new mothers in the hospital, held new babies and marveled at them.

So no, we weren’t totally consumed by these negative emotions, but they were always there… like a slacker college roommate who never left the couch. While our friends were largely unaware, we had to live with the negative emotion. We had to secretly wonder what it said about us. In some ways it was further confirmation that we were just bad people.


In talking to patients, I’ve come to realize how common these feelings are. With rare exception, patients have confessed that they feel this way, too. Nearly always, the patients are racked by guilt over these feelings. They think they are being petty and spiteful. They think they are terrible people because of it.

I tried to talk my way around these feelings, to shun them, to shut them out. But I have to confess, it was only after I could openly admit my feelings that I could begin to work through them.

These feelings were nothing, if not humbling. They were a reminder of my imperfection. But knowing how common these feelings are, knowing how imperfect so many of us are has also given me comfort.

Perhaps that’s why I’m so willing to share my experience with my patients. I can see the visible relief on their faces when I confess this story.

I give them permission to be angry. I am hoping they have the same experience I did: by embracing the pain, it starts to ease.



Afterthought:
Jim Benton, author of the very funny “Happy Bunny” series writes: “Hate is a special kind of love we give to people who suck.”

Hope

If you are like me and my wife, most of the time you’ve got things pretty well covered. The world seems to run better when you’re in charge, and for the most part, things go your way.

I think that’s partly why the diagnosis of infertility was so frustrating to us. It seemed like everything about it was out of our control. To make matters worse, a lot of current medical advice encouraged patients to educate themselves about their condition. While this is a good concept, it has a major pitfall: mainly, it gives you the sense that you do have more control over the situation than you actually do.

The more we tried to gain control of it, the more elusive getting pregnant became. The more frustrated we became.

This frustration and desire for control had many implications. I saw this as a patient and I continue to see this as a doctor.

The first casualty in this quest for control was our self esteem.

Getting pregnant was so easy for other people. We could not go to the mall or the grocery store without feeling like we had stumbled into a stroller stampede. Happy mothers and families were everywhere.

If it was so easy for them, then something was wrong with us. We had a sense that we were somehow not worthy, or that we were being punished.

To make matters worse, during much of our journey, I was an Ob/Gyn resident. Daily, I cared for couples who seemed to take their fertility for granted. I saw women (drug addicts, alcoholic) who made very unhealthy choices for their pregnancies. I saw 13 year old girls who thought that pregnancy was a perfectly normal part of adolescence.

It made me wonder what sin I had committed to make me unworthy of being a father.

This blame made us somehow doubt that any treatment would work. Success seemed so far away.

This blame skewed our ability to interpret what the doctors told us. When we were told that an individual treatment would have a 15% chance of working we somehow focused on that 15% only. That 15% received 100% of our attention. So when the most likely thing happened -- we did not conceive -- our disappointment was out of proportion to what our actual chances had been. We thought each failure was an indictment, or a failure of the doctor.

As I sit here and write this, there are so many tangential directions I could go explore. There are so many examples of how we gradually lost trust that we would ever conceive, but I won’t elaborate on them right now.

I can say that I think I know what kept us going.

First, we kept trying because despite each failure, we would have regretted not trying one more time.

Second, I knew I was not yet ready to adopt. At that time in my life, it seemed like "second best". And as long as I felt that way, I knew that would not be fair to a child. (Of course I felt guilty about this, too, and it only reinforced my doubts about whether I was worthy.)

But ultimately, despite all the guilt, despite wondering if we were being punished, I was hopeful.

I was hopeful that our suffering was a gift.

I didn’t know what kind of gift it would be: compassion and understanding for those in my shoes; a greater love for a child (adopted or otherwise) should we ever have one; a cautionary tale for others.

In the end, I learned that no matter how much I tried, I could not control hope. It controlled me.

This was how I came to realize that hope is at once wonderful… and cruel.